Mosaic International Corporation : Equipment Lease Financing Specialists  

Call us toll-free within the U.S. 1.800.805.1969

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Online Equipment Vendor Application
Items in bold are required.

VENDOR INFORMATION
Legal Name of Company:
 Contact Person:
 Title:
Name of Principal(s):
 Web Site Address:
Telephone Number:
 Fax Number:
 Email:
Street Address: (no P.O. boxes)
 City:
 State/Province:
 Zip/Postal Code:
Mailing/Invoice Address: (if different from above)
 City:
 State/Province:
 Zip/Postal Code:
Any previous business with Mosaic International Corporation? (If so, please specify.)
Type of product/service provided: (Please fax any applicable product literature or brochure to 612.395.5235)
BUSINESS INFORMATION
Date Established:
 Parent Company of:
 Division, Subsidiary or Affiliate of:
Dun and Bradstreet #:
 Taxpayer ID or EIN:
 Standard Industrial Clas- sification (SIC) Code:
 Number of Employees:
Sales Volume (past 3 years):
Year:
  $		 Year:
  $		 Year:
  $
FINANCIAL REFERENCES
If you would like to include more than two financial references, please fax the additional information to 612.395.5235
Bank Name:
 City:
 State:
 Telephone:
 Contact Name:
TRADE REFERENCES
If you would like to include more than two trade references, please fax the additional information to 612.395.5235
Company Name:
 City:
 State:
 Telephone:
 Contact Name:
BUSINESS CLASSIFICATION
Have you been certified by a federal, state, or municipal government or any of the local councils as a small disadvantaged business, woman-owned business, or both?
     (If yes, please fax certification documentation to 612.395.5235)

Please indicate the type of firm that exemplifies your company, by checking one or more of the following:
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Geographical Service Area:

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By clicking the submit button below, you are certifying to Mosaic International Corporation that all statements and all answers to the questions listed on this form are true and correct. You also agree that you or a representative of your company will advise Mosaic International Corporation if your classification should change.

equipment vendors  |  equipment leasing  |  municipal leasing  |  federal government leasing  |  leasing in canada  |  tribal leasing

1229 Third Street, Suite 201  ·  Int'l Falls, MN 56649       Phone: 800.805.1969 or 218.285.7421       Fax: 612.395.5235 or 218.285.7422
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